Provider Demographics
NPI:1265813901
Name:SELBY, EDWARD
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
Last Name:SELBY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 SHORE RD
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07821-2240
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:352 7TH AVE RM 10001
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-5012
Practice Address - Country:US
Practice Address - Phone:646-780-9979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-17
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020331103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical